Vitiligo - my experience of 25 years and 19156 patients by Dr. A.Salafia

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Dr. Antonio Salafia.

Presentation from the World Vitiligo Symposium 2011. Sponsored by the VR Foundation.

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Vitiligo - my experience of 25 years and 19156 patients by Dr. A.Salafia

  1. 1. Vitiligo: my experience of 25 years and 19.156 patients Dr. Antonio Salafia Dermatologist & Head Dept. Reconstructive Surgery. Vimala Dermatological Centre, Mumbai St.Petersburg, Russia. July 7th 2011
  2. 2. The experience of a clinician.• In the early 1980’s I was disappointed with PUVA, so I explored other avenues: a) From the year 1980 Dapsone was used at Vimala Dermatological Centre, with some success. b) In 1983 I set a protocol:Dapsone, Vitamin B6 -suggested by C. Frati from IDI,Rome.• In 1985 I began experimenting with new lotions, inspired by the work of Prota. (Protocol C). Antonio Salafia
  3. 3. Protocol ‘C’ORAL THERAPY:• Dapsone: 0.5 mgs K/wt.• Vitamin B6 100-300 mg. a day, Iron, Folic Acid.LOCAL APPLICATION:• Face: Locoid (Hydrocortisone Butyrate) Tacrolimus.• Neck: Lotion A (the mildest).• Body / Arms and Legs: Lotion B (strong).• Arms, Legs, Hands, Feet : Lotion 5 –F (strongest). Antonio Salafia
  4. 4. Dapsone: possible mode of action.a) Antioxidant: a. Potent scavenger of free radicals (T. Ryan) b. Decreases H2O2 - as good as Catalase (Wozel). c. Weak inhibitor of prostaglandin synthesis. d. Scavenger of oxidative intermediates, and suppressor of PMN (which produce ROS).B) Decreases the level of Glutathione: skin of vitiligo patients has a higher content of Glutathione. By suppressing Glutathione we favor the formation of Eumelanins instead of Pheomelanins (Ito).C) Possible beneficial effects. DDS is an immunomodulator + suppressor of PMN cells, hence effective in diseases wherein there is dense infiltrate of PMN: Dermatitis Herpetiformis, Subcorneal Pustular Dematosis, Scarring/ Bullous Pemphigoid and more than 20 other diseases. Antonio Salafia
  5. 5. Vitamin B6: importance.• Vitamin B6 is a potent antioxidant.• Involved in the homeostasis of Glutathione and Cysteine (switching mechanism of Ito).• In high doses, is capable of transforming Glutammic acid into Pyrrolecarboxylic acid and prevents the formation of Glutathione (Frati).• In my experience, it helps to prevent new patches, so I advise my pts. to keep on taking for years.• (It prevents homocysteine-induced atherosceloris in rats). Antonio Salafia
  6. 6. First experiments with my protocol and my lotions. Antonio Salafia
  7. 7. Face: Locoid Arms: Lotion B Cure in 6 months.Antonio Salafia
  8. 8. Lotion 5-FAntonio Salafia
  9. 9. Dapsone+B6and Locoid Antonio Salafia
  10. 10. Locoid… Lotion A Antonio Salafia
  11. 11. Protocol C + Lotion 5-F. Antonio Salafia
  12. 12. Face: Locoid. Neck: Lotion A Antonio Salafia
  13. 13. Lotion BAntonio Salafia
  14. 14. Lotion 5-F. Stopped oral medications and relapsed.Antonio Salafia
  15. 15. Chemical Vitiligo: Lotion A Antonio Salafia
  16. 16. Lt. Lotion B. Rt.Lotion 5-F Antonio Salafia
  17. 17. Lotion 5-F Antonio Salafia
  18. 18. Results in 8730 (out of 13.119)• Protocol ‘A’: Vitamins, Iron, Copper; creams: Betnovate/Placenta extract.• Protocol ‘B’ : Orally as above + Dapsone+ locally Locoid/ Betnovate.• Protocol ‘C’: Dapsone 0.5 -1.0 mg/k/w + all the Vitamins, Local application Children : Locoid for face, Lotion A for body. Adults: Face & Neck: Locoid / Lotion A /Tacrolimus. Body: Lotion B. Limbs: Lotion 5-F.• Protocol ‘D’ : all of these except Dapsone; in its place, oral steroids.• Given the large number of patients treated, protocol A can be considered as ‘control group’ vs. protocol ‘B’ and ‘C’’.• I cannot due ‘double-blind trials’ in patients who are desperate for a cure. Antonio Salafia
  19. 19. How to read the charts.• Worse/Nil = are self-explanatory.• Poor = improvement less than 25%.• Fair = improvement 25% to 50%.• Good = > 50% but < 75%.• Excellent = more than 75%.• Almost cure = extensive lesions, ‘cured’ except for one or two stubborn patches.• Cure = total and permanent cure. Antonio Salafia
  20. 20. Protocol A: Vitamins… Protocol A – 1673 pts.700600500400300200100 0 CURE AC E G F P N W Antonio Salafia
  21. 21. Protocol B: Vitamins+DDS Protocol B - 1587 pts.500400300200100 0 C AC EX G F P N W Antonio Salafia
  22. 22. Protocol C: DDS+Vitam+My Lotions Protocol C - 4661 pts.12001000 800 600 400 200 0 C AC EX G F P N W Antonio Salafia
  23. 23. Protocol D: Steroids + Vitamins + Lotions Results with Protocol D – 809 pts.200150100 50 0 C AC EX G F P N W Antonio Salafia
  24. 24. Protocol A – 1673700 Protocol C –600 1200 4661500 1000400 800300 600200 400100 200 0CURE AC E G F P N W 0 C AC EX G F P N W Protocol B - 1587 Protocol D – 809500 200 pts.400 150300200 100100 50 0 0 C AC EX G F P N W C AC EX G F P N W Antonio Salafia
  25. 25. Results could be better, and lately they are.Some patients could not follow the therapy because:- Sunlight not possible: working hours, ladies with lesions on chest, thighs; artificial lamps are costly.- Some patients live far away, even outside India…- Others changed residence, job, got married…- Some poor patients could not afford the treatment.- Others expected miracles.- Certain areas of the body are ‘difficult’ : fingers, toes, bony prominences…..- Few of them came to rule out ‘Leprosy”. Antonio Salafia
  26. 26. Private Patients from Jan. 2005 to Dec. 2008. 2940 pts.• Protocol C + Inj. Triamcinolone 40 or 20 mgs. I.M. once a month x 3 - 5.• Fast results (due to Kenacort) and• Consistent results (due to Dapsone and B6).• Patients treated 2940: report on ‘regulars’ only: i.e. 2012 cases. Antonio Salafia
  27. 27. Private Patients: Results.600500400300 1 – 19200 20 - >100 0 Cure A-cure Exc Good Fair Nil Worse Antonio Salafia
  28. 28. Cure Acure Excellent Good Fair Nil Worse Total_________________________________________________________• Face 427 301 375 175 56 37 0 1371-----------------------------------------------------------------------------------• Limbs 523 319 362 187 110 94 17 1822-----------------------------------------------------------------------------------• Hand/ Feet 71 52 95 104 159 287 31 819------------------------------------------------------------------------------------• Body 467 262 326 24 43 37 16 1175-----------------------------------------------------------------------------------• Vagina 58 21 33 17 14 21 0 164------------------------------------------------------------------------------------• Penis 15 11 16 30 42 31 5 150 Antonio Salafia
  29. 29. Results, as per area of the body.800 Face700600 Limbs (each)500 Hands/ Feet400 (each)300 Body200 Vagina100 (mucosa) Penis 0 (glans) Cure Excellent Fair Worse Antonio Salafia
  30. 30. 500 400 Results as per 300 body area: 200 Face Face: 1371 100 Body: 1175 0 Cure Good Worse Limbs: 1822 500600500 400400 300300 Limbs Body 200200 100100 0 0 Antonio Salafia
  31. 31. Results:300250200 Hand/ Feet Hands/ Feet: 819150 Vagina: 164 Glans Penis: 150100 50 060 5050 4040 Vagi 30 na30 Penis 2020 10100 0 Antonio Salafia
  32. 32. Applied Aloe Vera, got Vitiligo.Protocol C + Tacrolimus 0.1%. Antonio Salafia
  33. 33. Difficult cases Lotion A x 1 year. Antonio Salafia
  34. 34. First Locoid, then Lotion A. Antonio Salafia
  35. 35. Segmental: lotion A; 6 mth- 1year. Antonio Salafia
  36. 36. Arms: lotion 5-F. Face not responding to anything. Antonio Salafia
  37. 37. Good response in majority of patients:Face: lotion A. Legs: lotion 5-F. Antonio Salafia
  38. 38. Protocol C + Lotion A.: 3 months. (very irregular patients) 19 months. Antonio Salafia
  39. 39. Lotion A: 6 months.Antonio Salafia
  40. 40. Neck: Lotion A. Arms: Lotion B. Antonio Salafia
  41. 41. Father & Mother affected too. Antonio Salafia
  42. 42. Protocol C + Tacroz 0.1%: 20.08.2009 11.12.2009 4.04.2011Antonio Salafia
  43. 43. Lotion A:- 22.08.2008 - 19.09.2008- 5 months.Duration of Disease 8 years. Antonio Salafia
  44. 44. Lotion 5-F: 4 months. Antonio Salafia
  45. 45. Lotion 5-F: 4 months.(very irregular). Antonio Salafia
  46. 46. Face: Tacroz … Lotion AHands: Lotion 5-F. Antonio Salafia
  47. 47. Neck: A. Arms: 5-F, 4-6 months. Antonio Salafia
  48. 48. Face:Tacroz.Arms and Legs: Lotio 5-F. Antonio Salafia
  49. 49. Locoid: 6 months. Antonio Salafia
  50. 50. Lotion A. Antonio Salafia
  51. 51. Neck: Lotion A. Arms: Lotion 5-F. Antonio Salafia
  52. 52. Locoid: 5-6 months. 17 years later. Antonio Salafia
  53. 53. Neck: Lotion A.Legs: Lotion 5-F. Antonio Salafia
  54. 54. Tacroz 0.1. Arms: lotion 5-F. Antonio Salafia
  55. 55. Lotion A,Lotion 5-F. Antonio Salafia
  56. 56. Girl: Tacrolimus. CHILD: Vitix: worse, 9.8.2008. Locoid: 27.9.208 cure in 2 months. Antonio Salafia
  57. 57. Lotion A : 2 months.(treatment is going on) Antonio Salafia
  58. 58. Face: Locoid. Neck: Lotion A. After 2 months. (Photoes: 20.9.08 18.10.08 15.11.08) Antonio Salafia
  59. 59. Treated elsewhere with only locoid. Myprotocol + Locoid for face. Legs: A Antonio Salafia
  60. 60. Face Lotion A, Abdomen Lotion B Antonio Salafia
  61. 61. Patient lives in England: 4 months. Antonio Salafia
  62. 62. Lotion B: 2 months. 5 months.Antonio Salafia
  63. 63. Face:LocoidArms: Lotio 5-F:6 months.Disease Ext.Duration 8 yrs Antonio Salafia
  64. 64. Face:Locoid,Neck:Lotion AArms:Lot. B: 6 months Antonio Salafia
  65. 65. Tacroz 0.03%, later on Homeopathy x 2 years…Worse.Protocol C + Tacroz 0.1%. Photo 12.3.11 16.4.11 Antonio Salafia
  66. 66. Latest photos: 18 June of 2011. Antonio Salafia
  67. 67. ANA and anti-DNA –ve. Anti-Thyroglobulin +ve.Photos: 10.9.2010, 13.12.2010, 2.7.2011. Dapsone, Tacroz 0.1%, latest: Lotion A. Antonio Salafia
  68. 68. Surgery. Good and bad surgery. Antonio Salafia
  69. 69. Surgery done elsewhere by a well-known dermatosurgeon. Antonio Salafia
  70. 70. Punch graft by same dermato(surgeon). Antonio Salafia
  71. 71. Operated twice withpunch graft. Antonio Salafia
  72. 72. Conclusion: Most patients can be cured; but, there are difficult cases and difficult areas.We are still working on it, because our aim is set high.. Antonio Salafia
  73. 73. Antonio Salafia
  74. 74. Thanks to you all anda big thanks to the organizers. Antonio Salafia

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